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Last October, I attended a lecture at the University of Toronto given by Mark Lewis, Ph.D., a neuroscientist and professor of developmental psychology. A former addict himself and author of The Biology of Desire: Why Addiction is not a Disease, Lewis said that addiction is not a disease, but rather an exaggerated outcome of normal learning. He also said that addiction is not caused by drugs or alcohol, it’s caused by attraction, where each cycle of attraction builds synapses in the brain that continue to narrow one’s focus to seek out immediate rewards rather than pursue longer-term opportunities. Proximity, availability and ego fatigue collude with the rewired brain to impair decision-making ability, blunting the sense of time that is normally part of our sense of self and who we are striving to become.

Wasted

This Thursday, January 21, 2016, CBC’s The Nature of Things will air the documentary Wastedat 8:00 p.m. The show chronicles the journey of Mike Pond, a successful psychotherapist from Penticton, B.C. and an alcoholic-in-recovery, as he discovers new evidence-based addiction research and treatment options.

Filmmaker Maureen Palmer and Pond originally set out to help others battling substance abuse by filming his progress after his five years of sobriety. But shortly after filming began, Pond relapsed and drank again. Pond had been at rock bottom before: he lost his practice, home and family, and had ended up homeless in Vancouver. This new challenge brings a personal and real-time urgency to their quest to find a treatment that could work.

Alcoholics Anonymous doesn’t work for most people

The only treatment offered to Pond at the time was Alcoholics Anonymous (AA). No surprise there, since most people, including frontline healthcare providers, still believe AA is the only effective treatment for addiction.

But the program didn’t work for Pond. In fact, it doesn’t work for a majority of people with addiction problems, and those who can’t work the twelve steps often feel like failures, especially when “success” is defined as total abstinence. Dr. Bill Miller, Professor Emeritus at the University of New Mexico and one the world’s foremost addiction experts, argues for a radical shift in thinking. He looked at large data sets on outcomes of alcoholism treatment programs in the U.S. and found that one in four people had abstained for a year after treatment. For the other 75% who did drink in that year, their alcohol consumption was down by 87%. He says, “Now for any other chronic condition, a 25% complete remission and an 87% reduction in symptoms for everybody else would be astonishingly successful. We really disadvantage ourselves by saying you’re a failure if you have even a single recurrence of what was the reason why you were admitted in the first place.”

Brain research clues

After years of recriminations and feelings of shame and failure with his recent relapse, Pond says, “I don’t want to go get a drink. I want to go and get the effect of that drink.” He is relieved to learn that his brain is wired differently and that his addiction is not a lack of willpower. His score on a computer game to test the ability for self-control showed he has a high level of impulsivity. When he viewed pictures of alcoholic and non-alcoholic drinks while in an fMRI machine, he reported that he didn’t have cravings when looking at the pictures of booze, yet his brain images told a much different story. His brain showed increased activity in the same areas as a small group of people with alcohol dependence issues.

Image courtesy of CBC’s The Nature of Things.

New drug options for addiction

Pond travelled to Bellingham, Washington for a new drug treatment called naltrexone (Vivitrol), an injectable medicine that can block or blunt cravings for up to 30 days. The drug is not yet available in Canada as an injectable and the pill form is apparently rarely prescribed. According to the manufacturer Alkermes’ website, studies showed that patients who received the drug plus counselling experienced significantly fewer days of heavy drinking. The drug is intended for people who have stopped drinking large amounts of alcohol to help them avoid drinking again and is to be used together with counselling and social support. And some people, like Pond, have a genetic predisposition to respond better to the drug.

Another medication mentioned in the film is gabapentin; a drug primarily used to treat seizures and neuropathic pain but also for anxiety disorders, insomnia, hot flashes and bipolar disorder.

Watch the film to find out what happens

I’ve watched it and I think Wasted is an important documentary to reduce the stigma associated with addiction and encourage more people to get help. How we define success matters greatly. Our healthcare system needs to ensure that people dealing with addiction can access the range of evidence-based treatments that are now available, including medications and cognitive behavioural therapy.

No one should get kicked out of treatment for relapsing. I recall Mark Lewis saying in the lecture I attended last October that one of the most powerful ways to help addicts is to empower them in their recovery, utilize their desire for other goals and help them envision a future that looks beyond the immediate to see their life as a narrative that can move from the past to the present to the future. That Pond can reconnect with his motivation and his reasons for moving forward bodes very well for his continued recovery. Kudos to Pond and Palmer for filming his journey so that it may help others!

Bountiful Films and partner Magnify Digital are launching Addiction The Next Step, an online portal for families and loved ones of those battling substance abuse. It has an interactive guide with proven therapy and information about how to communicate in a manner that motivates a substance abuser to change while reducing family stress and fear.

Stop multitasking. Chunk your day into scheduled blocks of time for focusing on work.

Eliminate distractions. Turn off notifications and alerts. Consider using background music to get in the flow.

Master your email. Don’t use your inbox as a to-do list! Get your email inbox to zero using the same triage principles for the 5 steps for Getting Things Done. Set up rules to automate incoming emails. Unsubscribe from newsletters you no longer want. Read and triage your email at set times per day, e.g. 3 times, and set fetching frequency to a longer interval. Turn email off when you are focusing on work.

Outsource tasks. As independent communicators, we can’t really delegate to anyone else when we are both boss and employee. Instead, outsource the work you don’t like doing or that is not worth your time to do.

Here are the productivity resources I mentioned in my talk. I hope you find them helpful to get more things accomplished, increase your income and have a better work/life balance this year. Let me know if there are other systems that work for you.

Canada is a hotbed for the commercialization of regenerative medicine and stem cell discoveries. How appropriate, since two Canadian doctors, James Till and Ernest McCulloch discovered transplantable stem cells at the Ontario Cancer Institute in Toronto in 1961.

Accelerated growth in this industry sector is opening up new job opportunities for medical laboratory technologists. The benefits include working with scientific discoveries and leading-edge technologies to find exciting new treatment options that can help people living with devastating diseases and conditions.

Check out my story From Bench to Business in the Winter 2015 issue of the Canadian Journal of Medical Laboratory Science. I enjoyed interviewing Lianne Witt, technical director of laboratory and client services at Insception Lifebank, Canada’s largest private cord blood bank, and Emily Titus, manager of technology at CCRM. It was great to learn about their career paths and why they feel this is a great time to be working in the fields of regenerative medicine and stem cells.

What medical lab technologist wouldn’t want to work with specialized equipment such as the Microsquisher?

Click on the image below for the full story:

You may also be interested in reading some of my other posts on stem cells and learn more about why I am fascinated by the topic:

Do you know that there are several health risks from wearing high heels? I used to wear them daily when I had an office job, even though they hurt my feet sometimes and I didn’t need the extra height. Now it hurts to wear them at all because I have worn flats for so long.

For my recent story for The Costco Connection (US Edition), “Fancy feet follies,” I interviewed three experts: a podiatrist, a chiropractor and an orthopedic surgeon. They provided some great insights about how high heels can cause a wide range of health problems, from ligament tears and hammertoes to back and knee pain, and even gait issues. They also shared some great tips for reducing problems.

And from this 99 % INVISIBLE podcast, I learned that men were first to wear high heels. Horseback riders in the 10th century wore them to help their feet stay in the stirrups. Heels became female-only footwear sometime in the 18th century.

Switching around heel heights on different days can help, but I wonder why more women aren’t giving them up altogether.

The maxim “you are what you eat” might be truer than we think. Leading health experts have been saying for years that maintaining a healthy weight is complex and not just a simple matter of eating less and exercising more.

Part of the answer may lie in our microbiome, according to a new documentary called It Takes Guts, airing on CBC’s The Nature of Things on Thursday, October 29, 2015. From fecal transplants and poo capsules to foods that promote microbial diversity in our digestive tracts, this documentary directed by Leora Eisen promises a close look at the latest science.

I’m setting my PVR to make sure I catch this film. I’m interested to learn about:

why some foods make us fat, while others nourish healthy bacteria

if the rise in non-celiac gluten sensitivity is related to a decrease in microbiome diversity

does antiseptic mouthwash wipe out healthy bacteria we need

how germaphobic should we be – is it a balance?

When my son was in first year university, he shared a unit with two other students. I referred to them as the “biohazard boys,” given the state of their shared kitchen and washroom. As the year finished, I realized their slovenly ways were a testament to the hygiene hypothesis – the exposure to a range of pathogens must have strengthened their immune systems as none of them got sick.

I’m setting my PVR to make sure I catch this film. I’m interested to learn about:

why some foods make us fat, while others nourish healthy bacteria

if the rise in non-celiac gluten sensitivity is related to a decrease in microbiome diversity

does antiseptic mouthwash wipe out healthy bacteria we need

how germaphobic should we be – is it a balance?

When my son was in first year university, he shared a unit with two other students. I referred to them as the “biohazard boys,” given the state of their shared kitchen and washroom. As the year finished, I realized their slovenly ways were a testament to the hygiene hypothesis – the exposure to a range of pathogens must have strengthened their immune systems as none of them got sick.

I’m looking forward to learning how “processed food is like a ‘nuclear bomb’ destroying our microbes” and hearing how we can enrich our “inner rainforest” to find better health.

I may bristle a bit at the bombastic buzzwords in the press release, but for many people, maintaining a healthy weight can feel like a war. The expert lineup in this documentary is excellent and includes:

Dr. Arya Sharma, Chair of Obesity Research and Management at the University of Alberta (and a great interview for a story I wrote on diabetes news a few years ago)

Ed Yong, prolific science journalist, now a staff writer for The Atlantic

I love writing about health innovations that can help people, especially if they are simple solutions with thoughtful design. The anoDyne™ microneedle is a nifty Canadian innovation that promises pain-free injections. If you know someone who has to take daily medication injections, or just plain hates getting poked with needles anytime, read on.

Inventor Dr. Pankaj Modi was diagnosed with type 1 diabetes at the age of 16 and vowed then to invent a better solution than traditional needles that hurt. He teamed up with Dick Crawford, an engineer and owner of a design and construction company in Peterborough, Ontario and together, they developed and tested the design over nine years.

http://www.anodyne.life/join

Instead of going as deep as the muscle layer, the anoDyne™ microneedle only goes in a scant 1 mm to inject medication into the gap between skin layers. Since there are no nerve endings there, the injection is pain-free. Medication travels quickly to the blood stream via interstitial fluid.

The device is the size of a wine cork or a tube of lipstick and it can be used almost anywhere on the body where there is skin. Single-use doses are pre-loaded by a pharmacist according to a doctor’s prescription. After use, the needle retracts into the case with a click where it is locked inside and cannot be reused.

The design is patent-protected in more than 33 countries. Human clinical trials to measure drug uptake and pain tolerance for insulin delivery are starting in November 2015, led by Dr. Azar Azad, managing director of Mount Sinai Services in Toronto. The company is crowdfunding to raise money for these clinical trials. If successful, manufacturer PKA SoftTouch Corporation plans to approach pharmaceutical companies to commercialize the device.

It’s easy to see how this will be a great step forward for children with type 1 diabetes who must take daily insulin injections, but I think it could be great a great delivery method for a wide variety of injections, from vaccines to pain medications.

I was watching the Rugby World Cup 2015: Samoa vs. Scotland game on television this weekend and noticed this happy baby among the Scottish fans. Kudos to his parents for protecting his hearing!

Repeated exposure to loud sounds leads to hearing damage, and that damage is painless, irreversible and cumulative over your lifetime. The noise level at sporting events is easily in the dangerous zone, well above 85 decibels. Consider these quick facts from Health Canada:

If you are in a noisy environment and someone standing a metre away has to shout to be understood, the sound levels are probably higher than 85 dBA and you are at significant risk for permanent hearing loss if exposed daily for 8 hours or more.

If you are somewhere noisy and someone standing 30 cm away has to shout to be understood, the sound levels are likely higher than 95 dBA and you are at significant risk for permanent hearing loss if exposed daily for 45 minutes or more

If you are in a noisy place and someone has to shout into your ears to be understood (how annoying!), the sound levels are likely higher than 105 dBA and you are at significant risk for permanent hearing loss if exposed daily for 5 minutes or more

My guess is that sound level would be well over 105 dBA at many points in time over the 2.5-hour game.

On August 18, 2015, the FDA approved Addyi (flibanserin), a drug to treat “acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women.” The FDA defines HSDD as “low sexual desire that causes marked distress or interpersonal difficulty and is not due to a co-existing medical or psychiatric condition, problems within the relationship, or the effects of medication or other drug substance.”

That’s an interesting parsing of words since some of those parameters may not be mutually exclusive. (And what about situations where men are no longer desirable because of issues related to THEM?)

Much has been written in the last week in light of the FDA approval for Addyi. There are so many things that have me shaking my head. My first thought? Equality is nowhere near the same thing as equity.

It’s not “female Viagra.”

If you were following the news over the last two weeks, you likely heard Addyi referred to as the “female Viagra,” yet the FDA announcement said, “Prior to Addyi’s approval, there were no FDA-approved treatments for sexual desire disorders in men or women.”

Over at FierceBiotech, John Carroll says the FDA blundered badly on the Addyi approval and says that manufacturer Sprout Pharmaceuticals is benefitting from the viral hype around the “female Viagra” terminology. The FDA never invoked the “female Viagra” wording, but there was a concerted effort by the manufacturer to market a drug for female sexual disorder and others have written about how this drug approval rode in on the tide of the efforts by Even the Score, a collaborative initiative by “26 Organizations who believe that it’s time to level the playing field when it comes to the treatment of women’s sexual dysfunction.”

The manufacturer has no idea how Addyi works.

Originally an antidepressant that failed to win approval two times over, the drug works in the brain by altering neurotransmitters. However, the prescribing information states that the mechanism of action is unknown. This is disappointing, however not unusual given that there are a lot of drugs that have unknown mechanisms of action, e.g. anesthesia.

A lot of fuss and risk for a little more frisk.

provides women who respond with less than one more sexually satisfying events per month (0.5-0.7)

is recommended to be taken at bedtime because it has a sedating effect on the central nervous system: “Patients should not drive or engage in other activities requiring full alertness until at least 6 hours after taking Addyi and until they know how Addyi affects them.” (But what about women who would like to enjoy sex fully alert? Should they set an alarm for 4 am? Or plan for afternoon escapades?)

Second, she flagged for me that in the safety studies about alcohol, which were conducted among a small group of 25 people, 23 of the participants were MEN! Given that women are more susceptible to the toxic effects of alcohol than men, this is alarming. (This reminds me of the ridiculous refusal by some study authors last year to retract a paper from JAMA even after they admitted to including WOMEN in their study about the effects of testosterone replacement therapy and cardiovascular health in MEN…)

Is HSDD an invented disorder?

This paper in the Journal of Medical Ethics published online June 29, 2015 says that there is no established norm for sexual activity, feelings or desire, and concludes, therefore, that female hypoactive sexual disorder does not exist:

Condition branding is a marketing technique in which companies develop conditions concurrently with developing drugs; examples include gastro-oesophageal reflux disease, premenstrual dysphoric disorder, social anxiety disorder, erectile dysfunction and hypoactive sexual desire disorder. Although it is illegal for pharmaceutical companies to market drugs prior to regulatory approval, there are no restrictions on marketing diseases, and industry seeks to establish a disease state in the minds of clinicians years before an expected drug launch. Continuing medical education (CME) courses are an important part of promotion prior to drug approval and have become a key marketing tool for increasing clinician receptivity to new products. We systematically identified 14 free, internet-based, industry-funded, accredited CME modules on hypoactive sexual desire disorder in women which came out before a new drug, flibanserin, was being considered for regulatory approval in the USA. Common themes in these modules included the following: (1) Hypoactive sexual desire disorder is common, underdiagnosed and can have a profound effect on quality of life. (2) Women may not be aware that they are sick or distressed. (3) Simple questionnaires can assist clinicians in diagnosing the disorder. (4) It is problematic that there are medicines available to treat sexual problems for men but not women. In fact, there is no scientifically established norm for sexual activity, feelings or desire, and there is no evidence that hypoactive sexual desire disorder is a medical condition. Hypoactive sexual desire disorder is a typical example of a condition that was sponsored by industry to prepare the market for a specific treatment. (Bold emphasis mine).

Nomenclature follies.

Why is there no mention in Addyi’s prescribing information for the condition needing to be present for at least six months before diagnosing a woman with the disorder? The FDA’s summary of patient impact and scientific meetings held last October stated that HSDD falls under female sexual interest/arousal disorder (FSIAD) in the Fifth Edition of the Diagnostic and Statistical Manual (DSM-5), and mentioned the fact that the disorder needs to be present for 6 months before diagnosis. Yet there is no mention of this in the prescribing information that I can see.

The FDA approval was for HSDD, and the FDA meetings held last October discussed female sexual dysfunction (FSD) as an umbrella term: “The term FSD covers a heterogeneous collection of conditions that have previously been classified into four different disorders: hypoactive sexual desire disorder (HSDD) characterized by a reduced or absent interest in sexual activity, female sexual arousal disorder (FSAD) characterized by an inability to attain or maintain sexual excitement, female orgasmic disorder characterized by the difficulty to attain orgasm despite sufficient arousal, and sexual pain disorder characterized by pain during sexual intercourse.

In May 2013, HSDD and FSAD were combined into a single diagnosis of female sexual interest/arousal disorder (FSIAD) in the Fifth Edition of the Diagnostic and Statistical Manual (DSM-5). For a woman to be diagnosed with FSIAD, her symptoms of reduced sexual interest/arousal must have been present for at least six months, and must be severe enough to be a source of personal distress. FSIAD can be lifelong or acquired, range from mild to severe, and may be generalized or situational. There is currently no precise measure of the prevalence of FSIAD. However, one survey of U.S. women found that 12% of women reported experiencing personally distressing sexual problems. (Bold emphasis mine). Source: (PDF) The Voice of the Patient, A series of reports from the U.S. Food and Drug Administration’s (FDA’s) Patient-Focused Drug Development Initiative, Female Sexual Dysfunction Public Meeting: October 27, 2014 Report Date: June 2015.

What’s next for Addyi?

Health Canada often follows FDA approval, but not always. Interestingly, two days after the FDA approval, Addyi’s manufacturer, Sprout Pharmaceuticals of Raleigh, North Carolina was bought for $1 billion by Canadian company Valeant. The company plans to request Health Canada approval this fall.

Given that fall is just around the corner and those of us who live in northern latitudes are heading back into the seasons where we will have little to no chance to get natural vitamin D from the sun, I am revisiting a story I wrote more than a year ago: Vitamin D: Pros and Cons.

Vitamin d hype and debate continue

This past spring, large ads in Canadian newspapers claimed that no one is getting anywhere close to the amount of vitamin D needed and that we should increase our intake by 10-fold, from the 600-800 international units daily recommended by Health Canada (and the US Institute of Medicine), to a whopping 6,000-9,000 international units per day.

Canadian registered dietician Leslie Beck wrote in The Globe and Mail, “Osteoporosis experts are being inundated with calls from confused patients. Dietitians of Canada has expressed its concern in a letter to Health Canada. And Canadians are wondering what to make of the bold assertion that Health Canada was wrong and that we actually need more – a whole lot more – vitamin D to ward off disease. Do we?”

Those ads, placed by Pure North S’Energy Foundation, claimed that vitamin D deficiency is causing widespread illnesses and premature deaths. According to this story in The Globe and Mail, wealthy entrepreneur and chemical engineer Allan Markin, who claims he has invested $20 million in Pure North S’Energy Foundation, personally takes 12,000 IUs of vitamin D daily.

Measuring media hype about vitamin D

In a recent paper, Timothy Caulfield and colleagues examined the media coverage of vitamin D and how its role in health and the need for supplements were portrayed. Caulfield is a Canada Research Chair in Health Law and Policy and a Professor in the Faculty of Law and the School of Public Health at the University of Alberta. The paper was published in BMJ Open and a full copy is available here. The researchers surveyed 294 print articles from elite newspapers in the UK, US and Canada over a 5-year period and found that newspaper coverage generally:

supported supplementation for the general population

framed vitamin D as difficult to obtain from the food supply

asserted that vitamin D deficiency is a widespread public health issue

linked vitamin D to a wide range of health conditions for which there is no conclusive scientific evidence

downplayed the limitations of the existing science

overlooked the potential risks of supplementation

It’s no surprise to me that these researchers found 40 different health conditions mentioning a relationship to vitamin D. As I wrote a year ago, there is a flood of observational studies linking vitamin D deficiency to cancer, diabetes, cardiovascular diseases, autism, kidney disease, multiple sclerosis, chronic obstructive pulmonary disease, asthma, gum disease, arthritis, premenstrual syndrome, all-cause mortality and on it goes.

Health journalist André Picard wrote in The Globe and Mail that claims about vitamin D being a miracle drug that can prevent a wide range of illnesses are ridiculous: “These are preposterous claims based on the dubious premise that by hiking the amount of vitamin D in our blood, a broad range of illness would disappear,” and “the fundamental error here is confusing correlation and causation. Yes, people with adequate vitamin D levels have less disease. But it does not follow that pumping everyone full of supplements will make them healthier. Enthusiasm for this panacea simply doesn’t match the scientific evidence.”

Correlation is not causation. Still!

Yes indeed! As any health journalist worth their salt understands, the problem with observational studies is that we only learn that two things changed when we looked at their data together, NOT that changes in one of them caused changes in the other. [If you want to better understand how ridiculous it is to draw causal conclusions on observational data, check out Tyler Vigen’s Spurious Correlations, which started as a blog and is now available as a book. It’s hilarious!]

No matter how much readers or editors want to read about “dramatic new studies” to justify their beliefs that popping large amounts of vitamin D daily will improve their health or ward off a host of diseases, the truth is that answers about vitamin D’s effectiveness and safe upper intake levels can never be found in observational studies. Nor can we discern how much vitamin D people should take based on how far away from the equator they live (yes, that was a real question I was asked to field).

Best evidence on the horizon

So where do things stand? As far as I can tell, the same as they did a year ago. There is still no conclusive evidence that taking vitamin D supplements provides benefits beyond bone health — yet.

JoAnn Manson, MD, DrPH, Chief of Preventative Medicine at Brigham and Women’s Hospital and Professor of Medicine at Harvard Medical School (and who was on the IOM Committee that developed the current public health recommendations) said a year ago that the enthusiasm for vitamin D supplementation continues to outpace the evidence. She said that the evidence to date shows some vitamin D is good, but more is not necessarily better. There is limited research on long-term intakes above 2,000 IU daily and with very high doses of 10,000 IU daily or higher, people can develop a high level of calcium in the blood or urine, which can cause cardiovascular problems and kidney stones.

The best evidence on the horizon, as far as I can tell, is still the VITAL study (VITamin D and OmegA-3 Trial). Led by Dr. Manson and colleague Julie Buring, ScD, it’s a large-scale, randomized, double-blind, placebo-controlled prospective trial with an impressive design. The test groups and the comparison groups are designed to have a large enough difference in vitamin D levels to see if there is a meaningful difference in health outcomes. The study began in 2008 and results are expected in late 2017. I’m optimistic that this study will shed light on understanding how altering levels of vitamin D supplementation impacts on health conditions beyond bone health.

It may not be palatable for those looking for a panacea to wait until late 2017, but strong, evidence-based science takes time.

In the last several years, there has been a flood of health news about studies linking vitamin D deficiency with cancer, cardiovascular diseases, diabetes, metabolic disorders, depression, infectious diseases, autoimmune diseases, mortality and even autism. A search on PubMed for vitamin D finds more than 1,400 papers listed from January to April 2014 alone.

As a result of this increased interest, some people are boosting their intake above the recommended dietary allowance hoping that extra vitamin D might help prevent, treat or cure a host of adverse disease conditions.

Vitamin D supplementation is proven to be effective to help maintain good bone health, but can increasing intake above the current recommended dietary allowance really cure or prevent other health conditions?

Vitamin D and arthritis

Dawn Hunter, a freelance editor based in Toronto, Ontario, takes 2,000 IU (international units) of vitamin D daily, even though some health guidelines call for a much smaller dose of 600 IU per day. “Every time I stop taking it, my levels just plummet,” says Hunter, who has arthritis and says that she does not have the opportunity to get much natural sunshine.

Five years ago, Hunter found out she was severely deficient after her rheumatologist ordered a blood test. She addressed her deficiency by taking 4,000 IU daily for a year to boost her blood level from 14.8 ng/mL (nanograms per milliliter) and has been maintaining her level at 30.4 ng/mL with a daily dose of 2,000 IU for the past 4 years. (The normal range is 30.0 to 74.0 ng/mL).

“When my vitamin D level increased, I noticed a small reduction in the general ache I had with my arthritis,” notes Hunter. “My rheumatologist says there is some evidence that arthritis can progress faster in people who have low levels of vitamin D. I was just turning 40 when my arthritis was diagnosed, so managing progression is important to me.”

Vitamin D is really a hormone

Vitamin D is actually a pro-hormone that is involved in many metabolic processes. Your body makes vitamin D from sunlight on your skin. You can also take supplements and you can get a small amount from fortified food sources such as milk or orange juice.

Supplements come in two formats: vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Vitamin D2 is found naturally in sun-exposed mushrooms. Vitamin D3 is the form made naturally in human skin and is made from a cholesterol precursor obtained from lanolin. It can be found in oil-rich fish like salmon, mackerel and herring. There is some evidence that the D3 format is more bioavailable. Vitamin D is fat-soluble, meaning that if you take too much, the excess is not excreted in urine.

In your body, your liver converts vitamin D from sunlight or supplements to 25-hydroxyvitamin D, [25(OH)D], the form that is measured in a blood test. The 25 (OH)D is then converted again, mostly in the kidneys, to the activated form of vitamin D, a hormone called calcitriol (1,25-dihydroxyvitamin D).

It’s plausible that vitamin D may play a role in a host of other diseases and conditions such as cancer, cardiovascular disease and diabetes because there are calcitriol receptors on nearly all tissues in the body. Calcitriol plays a role in the regulation of over 900 different genes. In cell culture and animal studies, researchers have found that calcitriol is involved in cell differentiation, proliferation and inhibition, inflammation, and the synthesis and secretion of insulin. Calcitriol also has an impact on brain function and development. Two U.S. researchers recently proposed a mechanism to explain how calcitriol may be involved in the regulation of the production of serotonin, a brain chemical that is often out of balance in autistic children.

At first blush, it may seem hard to believe that vitamin D could be associated with so many different conditions. However, John J. Cannell, MD, Founder and Executive Director of the Vitamin D Council, says, “Many people are turned off by these claims and say it’s impossible that one thing is involved in so many different disease processes, but they are unaware of the mechanism of vitamin D. It is actually a steroid hormone precursor that turns genes on and off. There are at least a thousand genes that are directly regulated by vitamin D.”

Recent vitamin D studies

Here are some examples of recent studies that found a link between vitamin D and health conditions.

Cholesterol

Vitamin D may improve cholesterol numbers. A recent study analyzed data from 576 postmenopausal women who were part of the National Institute of Health’s Women’s Health Initiative trial. Women who took 400 IU of vitamin D plus 1,000 mg of calcium daily showed a significantly higher blood level of vitamin D after two years, compared to the control group who took a placebo. Interestingly, those who had higher blood levels of vitamin D also had better lipid profiles, showing increased high-density (“good”) cholesterol), decreased low-density (“bad”) cholesterol and lower triglycerides. The researchers acknowledge that the sample size was small and their findings are not conclusive about how vitamin D affects cardiovascular health. However, given that these results were from blood work for women followed for several years, there is a relationship here that merits further research. The study was published in the March 2014 issue of Menopause.

Breast cancer

Patients with higher levels of vitamin D at the time of breast cancer diagnosis may live longer. A recent meta-analysis combined data from more than 4,500 breast cancer patients from 5 observational studies to see if higher vitamin D levels at the time of breast cancer diagnosis were associated with longer patient survival times. Over a 9-year period, patients in the group with the highest blood level of 25-dihydroxyvitamin D [25(OH)D], (the form of vitamin D measured in blood tests), at an average level of 30 ng/mL, had about half the fatality rate compared to those in the group with the lowest level of 17 ng/mL on average. In the paper, researchers reported that other lab studies have shown that vitamin D has anticancer effects, arresting tumor growth in 3 critical phases of development. While these results are encouraging, the researchers caution that a causal conclusion is not possible and that a randomized controlled trial is needed to shed further light on the findings. The study was published in the March 2014 issue of Anticancer Research.

Risk of Mortality

Low vitamin D levels carry a greater risk of death. In a large systematic review and meta-analysis published in the April 2014 issue of the British Medical Journal, researchers looked at the link between vitamin D and chronic diseases to assess mortality risk. They combined data from several large databases of studies, including Medline, Embase and the Cochrane Library. Low blood levels of vitamin D were associated with a greater risk of death from cardiovascular disease, cancer and other causes. Calculations showed that each 10 ng/mL decline of 25(OH)D was associated with a 16% greater risk of mortality and that supplementation with vitamin D3 reduced mortality risk by 11%.

Autism

Vitamin D may play a role in abnormal social behavior seen in people with autism spectrum disorder. Rhonda Patrick, PhD, and Bruce Ames, PhD, at the Children’s Hospital Oakland Research Center (CHORI) in California, proposed a causal mechanism for how 3 brain hormones that influence social behavior — serotonin, oxytocin and vasopressin — are activated by vitamin D at the genetic level. These brain hormones are often out of balance in children with autism spectrum disorder. These researchers hypothesize that the drop in adequate levels of vitamin D in the U.S. over the past few decades — due in part to increased use of sunscreens and more indoor work — may in part explain the increase in autism rates. The study was published in the February issue of The Journal of the Federation of American Societies for Experimental Biology.

Different views on the ideal level of vitamin D?

Almost 70% of the U.S. population has insufficient levels of 25(OH)D, when defined as less than 30 ng/mL, according to data combined from many studies. The level of vitamin D in your body is measured by a blood test that measures 25-hydroxyvitamin D, [25(OH)D], the form of vitamin D that your body makes after converting what you receive from sunlight on skin, supplements or from some food sources, such as fortified milk and orange juice or from the flesh of fatty fish, including salmon, tuna and mackerel. The Vitamin D Council, a nonprofit organization based in California that works to educate the public about vitamin D, notes that there are several factors that affect how much vitamin D your body produces when your skin is exposed to sunlight. These factors include the time of year and time of day of exposure, where you live and the type of skin you have. You can request a blood test to check your vitamin D levels from your doctor, and the cost is usually covered in the U.S. if a doctor orders it with the right diagnostic code.

According to the Institute of Medicine (IOM), the current recommended dietary intake of 600 IU for adults under the age of 70 years and 800 IU for adults over 70 years is sufficient to meet the needs of 97.5% of healthy adults who have minimal sun exposure. The IOM defines sufficiency of 25(OH)D as greater than 20 ng/mL. This recommendation was based on proven benefits for bone health, as the IOM did not find convincing evidence about causal outcomes with other health conditions.

The Vitamin D Council recommends a much higher daily intake of 5,000 IU to achieve a sufficiency level of 50 ng/mL. Dr. Cannell says, “The Vitamin D Council arrived at a recommendation very simply — to reproduce natural vitamin D from sun exposure. We know that natural vitamin D levels for lifeguards and roofers and hunter/gatherers from modern-day Tanzania are about 50 ng/mL. Until all the studies are done and all the science is completed, the safest thing for you to do is to maintain a natural vitamin D level.”

The IOM, however, noted a concern for attaining levels above 50 ng/mL and designated 4,000 IU daily as the tolerable upper intake limit, with the caution that this is not to be interpreted as a target intake level. JoAnn E. Manson, MD, DrPH, Chief of Preventive Medicine at Brigham and Women’s Hospital and Professor of Medicine at Harvard Medical School, was on the IOM Committee that developed the guidelines. She says, “There’s still a pretty wide range of intake in the IOM guidelines. The recommended dietary allowance is what will meet the requirements for a very large majority of the population, 97.5% in the U.S. and Canada, but the IOM is also saying that there is a risk of adverse events at intake levels above 4,000 IU per day.”

Risks of too much vitamin D

How much is too much? Observational studies suggest that shooting for blood levels above 50 ng/mL may be associated with an increased risk of pancreatic cancer, cardiovascular disease and an increased risk of death. Dr. Manson says, “Some vitamin D is good, but more is not necessarily better. People should understand that there is limited research on long-term intakes above 2,000 IU daily. If they are regularly taking 3,000-4,000 IU per day, even if those levels may not have been linked to adverse events, we do not know if the benefits outweigh the risks long-term because we don’t have the evidence.”

Massive doses of 10,000 IU daily or more can put you at risk of developing high calcium levels in the blood, or in the urine, which could cause calcification of blood vessels, kidney problems and kidney stones, especially if calcium intake is also high.

Dr. Manson advises that it’s important to distinguish between public health guidelines and medical situations where individual patients actually need more vitamin D, such as those who have bone health problems, malabsorption or who are on medications that may interfere with the metabolism of vitamin D. For example, steroid drugs like prednisone, weight loss drugs like orlistat (Alli) and the cholesterol-lowering drug cholestyramine (Questran) can reduce the absorption of vitamin D.

The National Institute of Health (NIH) identifies a number of interactions of moderate concern, including with the cholesterol-lowering statin Lipitor: “Atorvastatin (Lipitor): Vitamin D might decrease the amount of atorvastatin (Lipitor) that enters the body. This might decrease how well atorvastatin (Lipitor) works.”

While there may be some situations that warrant higher doses of vitamin D, Dr. Manson cautions against taking mega-doses of the “sunshine” vitamin. “Clinicians still have latitude to make individualized recommendations for higher amounts for their patients, but the public health guidelines are saying that most of the population should not be taking high doses or getting blood screening tests regularly because there is no evidence to support that,” says Dr. Manson.

New evidence on the horizon

Experts are hoping a comprehensive trial underway called VITAL (VITamin D and OmegA-3TriaL) will reveal the true health benefits of vitamin D. Dr. Manson is lead investigator for this large-scale U.S. study among 10,000 adult women over 55 and 10,000 men over 50. She and her colleague, Julie Buring, DSc, are investigating if taking daily doses of 2,000 IU of vitamin D or a supplement of omega-3 fatty acids (Omacor fish oil, 1 gram) can reduce the risk of developing cancer, heart disease and stroke in healthy people with no history of these diseases.

The study is a randomized, double-blind, placebo-controlled trial where the test groups and the comparison groups will have a large enough difference in vitamin D levels to see if there is a meaningful difference in health outcomes. The study began in 2008 and is collecting data over an average of 5 years. The National Cancer Institute and the National Heart, Lung and Blood Institute are primary sponsors for the VITAL Study and final results are expected in late 2017.

Right now, the excitement about vitamin D is focused on the promise it offers in helping with a host of health conditions beyond bone health. “The enthusiasm is definitely outpacing the evidence,” notes Dr. Manson. “Although we know that vitamin D deficiency needs treatment, there is a disconnect between the observational studies that have linked low vitamin D to nearly every known health condition and the randomized trials of high-dose vitamin D supplements that have been largely disappointing to date. We do need the large-scale randomized trials, though, to test rigorously whether supplementation above the recommended dietary allowance confers greater health benefits.”

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